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Sen. Don Harmon
Filed: 4/15/2013
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1 | | AMENDMENT TO SENATE BILL 2366
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2 | | AMENDMENT NO. ______. Amend Senate Bill 2366 by replacing |
3 | | everything after the enacting clause with the following:
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4 | | "Section 5. The State Employees Group Insurance Act of 1971 |
5 | | is amended by changing Section 6.11 as follows:
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6 | | (5 ILCS 375/6.11)
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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 356g, |
13 | | 356g.5, 356g.5-1, 356m,
356u, 356w, 356x, 356z.2, 356z.4, |
14 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, |
15 | | 356z.14, 356z.15, and 356z.17 , and 356z.22 and 356z.19 of the
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16 | | Illinois Insurance Code.
The program of health benefits must |
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1 | | comply with Sections 155.22a, 155.37, and 356z.19 of the
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2 | | Illinois Insurance Code.
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3 | | Rulemaking authority to implement Public Act 95-1045, if |
4 | | any, is conditioned on the rules being adopted in accordance |
5 | | with all provisions of the Illinois Administrative Procedure |
6 | | Act and all rules and procedures of the Joint Committee on |
7 | | Administrative Rules; any purported rule not so adopted, for |
8 | | whatever reason, is unauthorized. |
9 | | (Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; |
10 | | 96-639, eff. 1-1-10; 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; |
11 | | 97-343, eff. 1-1-12; 97-813, eff. 7-13-12.) |
12 | | Section 10. The Counties Code is amended by changing |
13 | | Section 5-1069.3 as follows: |
14 | | (55 ILCS 5/5-1069.3)
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15 | | Sec. 5-1069.3. Required health benefits. If a county, |
16 | | including a home
rule
county, is a self-insurer for purposes of |
17 | | providing health insurance coverage
for its employees, the |
18 | | coverage shall include coverage for the post-mastectomy
care |
19 | | benefits required to be covered by a policy of accident and |
20 | | health
insurance under Section 356t and the coverage required |
21 | | under Sections 356g, 356g.5, 356g.5-1, 356u,
356w, 356x, |
22 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, |
23 | | 356z.14, and 356z.15 , and 356z.22 of
the Illinois Insurance |
24 | | Code. The coverage shall comply with Sections 155.22a and |
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1 | | 356z.19 of
the Illinois Insurance Code. The requirement that |
2 | | health benefits be covered
as provided in this Section is an
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3 | | exclusive power and function of the State and is a denial and |
4 | | limitation under
Article VII, Section 6, subsection (h) of the |
5 | | Illinois Constitution. A home
rule county to which this Section |
6 | | applies must comply with every provision of
this Section.
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7 | | Rulemaking authority to implement Public Act 95-1045, if |
8 | | any, is conditioned on the rules being adopted in accordance |
9 | | with all provisions of the Illinois Administrative Procedure |
10 | | Act and all rules and procedures of the Joint Committee on |
11 | | Administrative Rules; any purported rule not so adopted, for |
12 | | whatever reason, is unauthorized. |
13 | | (Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; |
14 | | 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; |
15 | | 97-813, eff. 7-13-12.) |
16 | | Section 15. The Illinois Municipal Code is amended by |
17 | | changing Section 10-4-2.3 as follows: |
18 | | (65 ILCS 5/10-4-2.3)
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19 | | Sec. 10-4-2.3. Required health benefits. If a |
20 | | municipality, including a
home rule municipality, is a |
21 | | self-insurer for purposes of providing health
insurance |
22 | | coverage for its employees, the coverage shall include coverage |
23 | | for
the post-mastectomy care benefits required to be covered by |
24 | | a policy of
accident and health insurance under Section 356t |
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1 | | and the coverage required
under Sections 356g, 356g.5, |
2 | | 356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10, |
3 | | 356z.11, 356z.12, 356z.13, 356z.14, and 356z.15 , and 356z.22 of |
4 | | the Illinois
Insurance
Code. The coverage shall comply with |
5 | | Sections 155.22a and 356z.19 of
the Illinois Insurance Code. |
6 | | The requirement that health
benefits be covered as provided in |
7 | | this is an exclusive power and function of
the State and is a |
8 | | denial and limitation under Article VII, Section 6,
subsection |
9 | | (h) of the Illinois Constitution. A home rule municipality to |
10 | | which
this Section applies must comply with every provision of |
11 | | this Section.
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12 | | Rulemaking authority to implement Public Act 95-1045, if |
13 | | any, is conditioned on the rules being adopted in accordance |
14 | | with all provisions of the Illinois Administrative Procedure |
15 | | Act and all rules and procedures of the Joint Committee on |
16 | | Administrative Rules; any purported rule not so adopted, for |
17 | | whatever reason, is unauthorized. |
18 | | (Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; |
19 | | 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; |
20 | | 97-813, eff. 7-13-12.) |
21 | | Section 20. The School Code is amended by changing Section |
22 | | 10-22.3f as follows: |
23 | | (105 ILCS 5/10-22.3f)
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24 | | Sec. 10-22.3f. Required health benefits. Insurance |
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1 | | protection and
benefits
for employees shall provide the |
2 | | post-mastectomy care benefits required to be
covered by a |
3 | | policy of accident and health insurance under Section 356t and |
4 | | the
coverage required under Sections 356g, 356g.5, 356g.5-1, |
5 | | 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.11, 356z.12, |
6 | | 356z.13, 356z.14, and 356z.15 , and 356z.22 of
the
Illinois |
7 | | Insurance Code.
Insurance policies shall comply with Section |
8 | | 356z.19 of the Illinois Insurance Code. The coverage shall |
9 | | comply with Section 155.22a of
the Illinois Insurance Code.
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10 | | Rulemaking authority to implement Public Act 95-1045, if |
11 | | any, is conditioned on the rules being adopted in accordance |
12 | | with all provisions of the Illinois Administrative Procedure |
13 | | Act and all rules and procedures of the Joint Committee on |
14 | | Administrative Rules; any purported rule not so adopted, for |
15 | | whatever reason, is unauthorized. |
16 | | (Source: P.A. 96-139, eff. 1-1-10; 96-328, eff. 8-11-09; |
17 | | 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; |
18 | | 97-813, eff. 7-13-12.) |
19 | | Section 25. The Illinois Insurance Code is amended by |
20 | | adding Section 356z.22 as follows: |
21 | | (215 ILCS 5/356z.22 new) |
22 | | Sec. 356z.22. Telehealth. |
23 | | (a) The General Assembly finds and declares the following: |
24 | | (1) Lack of primary care providers, specialty |
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1 | | providers, and transportation continue to be significant |
2 | | barriers to access to health services in medically |
3 | | underserved rural and urban areas. |
4 | | (2) Parts of Illinois have difficulty attracting and |
5 | | retaining health professionals, as well as supporting |
6 | | local health facilities to provide a continuum of health |
7 | | care. |
8 | | (3) Individuals in rural areas are much less likely to |
9 | | have access to the specialty health services they need, due |
10 | | to major distance and time barriers, transportation |
11 | | limitations, or mobility limitations, all of which lead to |
12 | | disparities in access to care. |
13 | | (4) Hospital emergency rooms have become the default |
14 | | provider of health care to patients with acute crises and |
15 | | for whom no appropriate alternatives are available, and the |
16 | | majority of emergency rooms do not have reliable, ready |
17 | | consultative access to psychiatrists or other medical |
18 | | specialties. |
19 | | (5) Telehealth has been shown to be an effective medium |
20 | | through which to deliver physical health and mental health |
21 | | care. |
22 | | (6) Key findings from the Illinois Rural Health |
23 | | Association's Mental Health Access Forum Report recommend |
24 | | the increased use of telehealth and technology to improve |
25 | | access to care, increase training opportunities, and |
26 | | evaluate quality of care. |
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1 | | (7) The State of Illinois has already recognized, and |
2 | | currently reimburses providers for, telepsychiatry |
3 | | services to patients receiving State public aid. |
4 | | (8) Telehealth is a mode of delivering health care |
5 | | services of a personal, family, and public health nature |
6 | | through utilizing information and communication |
7 | | technologies to enable the examination, diagnosis, |
8 | | consultation, treatment, education, care management, and |
9 | | self-management of patients at a distance from health
care |
10 | | providers. |
11 | | (9) The use of information and telecommunication |
12 | | technologies to deliver health services has the potential |
13 | | to reduce costs, improve quality, change the conditions of |
14 | | practice, and improve access to health care, particularly |
15 | | in rural and other medically underserved areas, as well as |
16 | | in emergency rooms in large urban areas where the wait for |
17 | | specialty care can be lengthy. |
18 | | (10) Telehealth will assist in maintaining or |
19 | | improving the physical and economic health of medically |
20 | | underserved communities by keeping the source of medical |
21 | | care in the local area by assisting primary care |
22 | | physicians, strengthening the health infrastructure, and |
23 | | preserving health care-related jobs. |
24 | | (11) Consumers of health care will benefit from |
25 | | telehealth in many ways, including expanded access to |
26 | | providers, faster and more convenient treatment, better |
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1 | | continuity of care, reduction of lost work time and travel |
2 | | costs, and the ability to remain with support networks. |
3 | | (12) It is the intent of the General Assembly that the |
4 | | fundamental health care provider-patient relationship not |
5 | | only be preserved, but also be augmented and enhanced, |
6 | | through the use of telehealth as a tool to be integrated |
7 | | into practices. |
8 | | (13)
Without the assurance of payment and the |
9 | | resolution of legal and policy barriers, the full potential |
10 | | of telehealth will not be realized. |
11 | | The purpose of this Section is to require certain insurers, |
12 | | nonprofit health service plans, managed care organizations, |
13 | | and health maintenance organizations to provide coverage for |
14 | | health care services delivered through telehealth in a certain |
15 | | manner; prohibit certain insurers, nonprofit health service |
16 | | plans, health maintenance organizations and managed care |
17 | | organizations from excluding a health care service from |
18 | | coverage solely because it is delivered by telehealth and not |
19 | | in another manner; require certain insurers, nonprofit health |
20 | | service plans, and health maintenance organizations to |
21 | | reimburse health care providers for certain services under |
22 | | certain circumstances; authorize the imposition of a |
23 | | deductible, copayment, coinsurance amount, or annual dollar |
24 | | maximum for certain services in compliance with Illinois and |
25 | | federal parity laws; prohibit the imposition of a lifetime |
26 | | dollar maximum for certain services; prohibit a health |
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1 | | insurance policy or contract from distinguishing between |
2 | | patients in rural or urban locations in providing certain |
3 | | coverage; and provide for the application of this Code. |
4 | | (b) For the purposes of this Section: |
5 | | "Asynchronous store and forward" means the transmission of |
6 | | a patient's medical information from an originating site to the |
7 | | health care provider at a distant site without the presence of |
8 | | the patient. |
9 | | "Distant site" means the location at which the provider |
10 | | rendering the service is located. |
11 | | "Facility fee" means the reimbursement made to the |
12 | | following originating sites for the telehealth service: |
13 | | physician's office, local health departments, community mental |
14 | | health centers, rural health clinics, hospitals, and substance |
15 | | use disorder facilities licensed by the Department of Human |
16 | | Services or the Department of Public Health. |
17 | | "Health care provider" means a licensed or certified health |
18 | | care professional, including, but not limited to, advanced |
19 | | practice nurses, psychologists, social workers, physicians, |
20 | | licensed clinical professional counselors, and mental health |
21 | | professionals as defined in 59 Ill. Adm. Code 132.25 and |
22 | | substance use disorder professionals as defined in 77 Ill. Adm. |
23 | | Code 2060.309. |
24 | | "Interactive telecommunications system" means multimedia |
25 | | communications equipment that includes, at a minimum, audio and |
26 | | video equipment permitting 2-way, real-time interactive |
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1 | | communication between the patient and the distant site |
2 | | provider. Telephones, facsimile machines, and electronic mail |
3 | | systems do not meet the definition of "interactive |
4 | | telecommunications system". |
5 | | "Originating site" means the location at which the |
6 | | participant receiving the service is located, including, but |
7 | | not limited to, hospitals, rural health clinics, Federally |
8 | | Qualified Health Centers, and other health care providers. |
9 | | "Physician" means a physician licensed to practice |
10 | | medicine in all its branches. |
11 | | "Synchronous interaction" means a real-time interaction |
12 | | between a patient at an originating site and a health care |
13 | | provider located at a distant site. |
14 | | "Telecommunication system" means an asynchronous store and |
15 | | forward technology or an interactive telecommunications |
16 | | system, or both, that is used to transmit data between the |
17 | | originating and distant sites. |
18 | | "Telehealth" means (1) the provision of services and the |
19 | | mode of delivering health care services and public health via |
20 | | information and communication technologies to facilitate the |
21 | | examination, assessment, diagnosis, consultation, treatment, |
22 | | education, care management, and self-management of a patient's |
23 | | health care while the patient is at the originating site and |
24 | | the health care provider is at a distant site; telehealth |
25 | | facilitates patient self-management and caregiver support for |
26 | | patients and includes synchronous interactions
and |
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1 | | asynchronous store and forward transfers and (2) as it relates |
2 | | to the delivery of health care, mental health care, substance |
3 | | use disorder treatment, and public health services, the use of |
4 | | interactive audio, video, or other telecommunications or |
5 | | electronic technology by a health care provider to deliver a |
6 | | health care service within the scope of practice of the health |
7 | | care provider from the distant site to the originating site at |
8 | | which the patient is located; telehealth is the provision of |
9 | | services via information and communication technologies to |
10 | | facilitate the assessment, diagnosis, consultation, treatment, |
11 | | education, care management, and self-management of a patient's |
12 | | health care while the patient is at the originating site and |
13 | | the health care provider is at a distant site; telehealth |
14 | | facilitates patient self-management and caregiver support for |
15 | | patients and includes synchronous interactions and |
16 | | asynchronous store and forward transfers.
"Telehealth" does |
17 | | not include: |
18 | | (A) an audio-only telephone conversation between a |
19 | | health care provider and a patient; |
20 | | (B) an electronic mail message between a health care |
21 | | provider and a patient; or |
22 | | (C) a facsimile transmission between a health care |
23 | | provider and a patient. |
24 | | "Teleophthalmology and teledermatology by store and |
25 | | forward" means an asynchronous transmission of medical |
26 | | information to be reviewed at a later time by a physician at a |
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1 | | distant site who is trained in ophthalmology or dermatology or, |
2 | | for teleophthalmology, by an optometrist who is licensed |
3 | | pursuant to the Illinois Optometric Practice Act of 1987 where |
4 | | the physician or optometrist at the distant site reviews the |
5 | | medical information without the patient being present in real |
6 | | time. |
7 | | (c) This Section applies to: |
8 | | (1) insurers and nonprofit health service plans that |
9 | | provide hospital, medical, mental health, substance use |
10 | | disorder, or surgical benefits to individuals or groups on |
11 | | an expense-incurred basis under health insurance policies |
12 | | or contracts that are issued or delivered in this State; |
13 | | and |
14 | | (2) health maintenance organizations that provide |
15 | | hospital, medical, mental health, substance use disorder, |
16 | | or surgical benefits to individuals or groups under |
17 | | contracts that are issued or delivered in this State. |
18 | | This Section shall not be construed to alter the scope of |
19 | | practice of any health care provider or authorize the delivery |
20 | | of health care services in a setting or in a manner not |
21 | | otherwise authorized by law.
All laws regarding the |
22 | | confidentiality of health care information and a patient's |
23 | | rights to his or her medical information shall apply to |
24 | | telehealth interactions. This Section applies to a group or |
25 | | individual policy of accident and health insurance or managed |
26 | | care plan amended, delivered, issued, or renewed after the |
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1 | | effective date of this amendatory Act of the 98th General |
2 | | Assembly. |
3 | | (d) An entity subject to this Section: |
4 | | (1) shall provide coverage under a health insurance |
5 | | policy or contract for health care services appropriately |
6 | | delivered through telehealth; |
7 | | (2) may not exclude from coverage a health care service |
8 | | solely because it is provided through telehealth and is not |
9 | | provided through an in-person consultation or contact |
10 | | between a health care provider and a patient; and |
11 | | (3) shall not require that in-person contact occur |
12 | | between a health care provider and a patient before payment |
13 | | is made for the covered services appropriately provided |
14 | | through telehealth. |
15 | | No health care service plan shall require the health care |
16 | | provider to document a barrier to an in-person visit for |
17 | | coverage of services to be provided via telehealth. No health |
18 | | care service plan shall limit the type of setting where |
19 | | services are provided for the patient or by the health care |
20 | | provider before payment is made for the covered services |
21 | | appropriately provided through telehealth, subject to the |
22 | | terms and conditions of the contract entered into between the |
23 | | enrollee or subscriber and the health care service plan and its |
24 | | participating providers or provider groups. |
25 | | Notwithstanding any other provision, this Section shall |
26 | | not be interpreted to authorize a health care service plan to |
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1 | | require the use of telehealth when the health care provider has |
2 | | determined that it is not appropriate. |
3 | | (e) With regard to reimbursement, an entity subject to this |
4 | | Section: |
5 | | (1) shall reimburse a health care provider for the |
6 | | examination, assessment, diagnosis, consultation, and |
7 | | treatment of an insured patient for a health care service |
8 | | covered under a health insurance policy or contract that |
9 | | can appropriately be provided through telehealth; |
10 | | (2) is not required to: |
11 | | (A) reimburse a health care provider for a health |
12 | | care service delivered in person or through telehealth |
13 | | that is not a covered benefit under the health |
14 | | insurance policy or contract; or |
15 | | (B) reimburse a health care provider who is not a |
16 | | covered provider under the health insurance policy or |
17 | | contract; |
18 | | (3) may impose the same deductible, copayment, or |
19 | | coinsurance amount on benefits for health care services |
20 | | that are delivered through an in-person consultation or |
21 | | through telehealth in compliance with Illinois and federal |
22 | | parity laws; and |
23 | | (4) may not impose a lifetime dollar maximum or limit |
24 | | the provision of mental health or substance use disorder |
25 | | services in a manner that violates Illinois or federal |
26 | | parity laws. |
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1 | | A facility fee shall be paid to providers. Participating |
2 | | providers shall be reimbursed for the appropriate current |
3 | | procedural terminology (CPT) code for the telehealth service |
4 | | rendered. |
5 | | (f) A patient receiving services by store and forward shall |
6 | | be notified of the right to receive interactive communication |
7 | | with the distant specialist physician or optometrist, and shall |
8 | | receive an interactive communication with the distant |
9 | | specialist physician or optometrist upon request. If |
10 | | requested, communication with the distant specialist physician |
11 | | or optometrist may occur either at the time of the consultation |
12 | | or within 30 days after the patient's notification of the |
13 | | results of the consultation. If the reviewing optometrist |
14 | | identifies a disease or condition requiring consultation or |
15 | | referral, then that consultation or referral shall be with an |
16 | | ophthalmologist or other appropriate physician and surgeon as |
17 | | required. |
18 | | (g) The requirements for telehealth services are as |
19 | | follows: |
20 | | (1) A physician or other health care provider must be |
21 | | onsite and available to the patient at the originating |
22 | | site, except: |
23 | | (A) where the patient requests that the health care |
24 | | provider not be present in the same room with the |
25 | | patient, but such health care provider is otherwise |
26 | | available to the patient onsite; or |
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1 | | (B) where the patient and his or her treating |
2 | | health care provider consent to the provision of level |
3 | | one substance use disorder treatment services in |
4 | | accordance with 77 Ill. Adm. Code 2060.401 without a |
5 | | health care provider present onsite with the patient. |
6 | | (2) The distant site provider must be a physician or |
7 | | health care provider. |
8 | | (3) Medical data may be exchanged through a |
9 | | telecommunication system. |
10 | | (4) The interactive telecommunications system must, at |
11 | | a minimum, have the capability of allowing the consulting |
12 | | physician to examine the patient sufficiently to allow |
13 | | proper diagnosis. The system must also be capable of |
14 | | transmitting clearly audible sounds as well as clear video |
15 | | images. |
16 | | (h) The requirements for telepsychiatry services are as |
17 | | follows: |
18 | | (1) A physician or other health care provider as |
19 | | defined in 59 Ill. Adm. Code 132.25 must be onsite and |
20 | | available to the patient at the originating site, but at |
21 | | the patient's request does not need to be present in the |
22 | | room with the patient. |
23 | | (2) The distant site provider must be a physician or |
24 | | health care provider licensed by the State of Illinois or |
25 | | by the state where the patient is located and must have |
26 | | completed or be registered in and supervised by a physician |
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1 | | who has completed an approved general psychiatry residency |
2 | | program. When treating patients age 16 and younger, the |
3 | | physician must have also completed an approved child and |
4 | | adolescent residency program or be registered in an |
5 | | approved general psychiatry residency program or a child |
6 | | and adolescent psychiatry fellowship program and |
7 | | supervised by a physician who has completed an approved |
8 | | child and adolescent psychiatry fellowship program. The |
9 | | distant site provider must personally render the |
10 | | telepsychiatry service. Telepsychiatry services must be |
11 | | rendered using an interactive video telecommunications |
12 | | system. |
13 | | Group psychotherapy is a covered telepsychiatry service. |
14 | | (i) The originating site must maintain records to document |
15 | | the services provided to patients and the health care providers |
16 | | involved in the services at all originating and distant site |
17 | | locations.
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18 | | Section 30. The Health Maintenance Organization Act is |
19 | | amended by changing Section 5-3 as follows:
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20 | | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
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21 | | Sec. 5-3. Insurance Code provisions.
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22 | | (a) Health Maintenance Organizations
shall be subject to |
23 | | the provisions of Sections 133, 134, 136, 137, 139, 140, 141.1,
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24 | | 141.2, 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, |
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1 | | 154.5, 154.6,
154.7, 154.8, 155.04, 155.22a, 355.2, 355.3, |
2 | | 356g.5-1, 356m, 356v, 356w, 356x, 356y,
356z.2, 356z.4, 356z.5, |
3 | | 356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13, |
4 | | 356z.14, 356z.15, 356z.17, 356z.18, 356z.19, 356z.21, 356z.22, |
5 | | 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, 368e, |
6 | | 370c,
370c.1, 401, 401.1, 402, 403, 403A,
408, 408.2, 409, 412, |
7 | | 444,
and
444.1,
paragraph (c) of subsection (2) of Section 367, |
8 | | and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, XIII 1/2, XXV, |
9 | | and XXVI of the Illinois Insurance Code.
|
10 | | (b) For purposes of the Illinois Insurance Code, except for |
11 | | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health |
12 | | Maintenance Organizations in
the following categories are |
13 | | deemed to be "domestic companies":
|
14 | | (1) a corporation authorized under the
Dental Service |
15 | | Plan Act or the Voluntary Health Services Plans Act;
|
16 | | (2) a corporation organized under the laws of this |
17 | | State; or
|
18 | | (3) a corporation organized under the laws of another |
19 | | state, 30% or more
of the enrollees of which are residents |
20 | | of this State, except a
corporation subject to |
21 | | substantially the same requirements in its state of
|
22 | | organization as is a "domestic company" under Article VIII |
23 | | 1/2 of the
Illinois Insurance Code.
|
24 | | (c) In considering the merger, consolidation, or other |
25 | | acquisition of
control of a Health Maintenance Organization |
26 | | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
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1 | | (1) the Director shall give primary consideration to |
2 | | the continuation of
benefits to enrollees and the financial |
3 | | conditions of the acquired Health
Maintenance Organization |
4 | | after the merger, consolidation, or other
acquisition of |
5 | | control takes effect;
|
6 | | (2)(i) the criteria specified in subsection (1)(b) of |
7 | | Section 131.8 of
the Illinois Insurance Code shall not |
8 | | apply and (ii) the Director, in making
his determination |
9 | | with respect to the merger, consolidation, or other
|
10 | | acquisition of control, need not take into account the |
11 | | effect on
competition of the merger, consolidation, or |
12 | | other acquisition of control;
|
13 | | (3) the Director shall have the power to require the |
14 | | following
information:
|
15 | | (A) certification by an independent actuary of the |
16 | | adequacy
of the reserves of the Health Maintenance |
17 | | Organization sought to be acquired;
|
18 | | (B) pro forma financial statements reflecting the |
19 | | combined balance
sheets of the acquiring company and |
20 | | the Health Maintenance Organization sought
to be |
21 | | acquired as of the end of the preceding year and as of |
22 | | a date 90 days
prior to the acquisition, as well as pro |
23 | | forma financial statements
reflecting projected |
24 | | combined operation for a period of 2 years;
|
25 | | (C) a pro forma business plan detailing an |
26 | | acquiring party's plans with
respect to the operation |
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1 | | of the Health Maintenance Organization sought to
be |
2 | | acquired for a period of not less than 3 years; and
|
3 | | (D) such other information as the Director shall |
4 | | require.
|
5 | | (d) The provisions of Article VIII 1/2 of the Illinois |
6 | | Insurance Code
and this Section 5-3 shall apply to the sale by |
7 | | any health maintenance
organization of greater than 10% of its
|
8 | | enrollee population (including without limitation the health |
9 | | maintenance
organization's right, title, and interest in and to |
10 | | its health care
certificates).
|
11 | | (e) In considering any management contract or service |
12 | | agreement subject
to Section 141.1 of the Illinois Insurance |
13 | | Code, the Director (i) shall, in
addition to the criteria |
14 | | specified in Section 141.2 of the Illinois
Insurance Code, take |
15 | | into account the effect of the management contract or
service |
16 | | agreement on the continuation of benefits to enrollees and the
|
17 | | financial condition of the health maintenance organization to |
18 | | be managed or
serviced, and (ii) need not take into account the |
19 | | effect of the management
contract or service agreement on |
20 | | competition.
|
21 | | (f) Except for small employer groups as defined in the |
22 | | Small Employer
Rating, Renewability and Portability Health |
23 | | Insurance Act and except for
medicare supplement policies as |
24 | | defined in Section 363 of the Illinois
Insurance Code, a Health |
25 | | Maintenance Organization may by contract agree with a
group or |
26 | | other enrollment unit to effect refunds or charge additional |
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1 | | premiums
under the following terms and conditions:
|
2 | | (i) the amount of, and other terms and conditions with |
3 | | respect to, the
refund or additional premium are set forth |
4 | | in the group or enrollment unit
contract agreed in advance |
5 | | of the period for which a refund is to be paid or
|
6 | | additional premium is to be charged (which period shall not |
7 | | be less than one
year); and
|
8 | | (ii) the amount of the refund or additional premium |
9 | | shall not exceed 20%
of the Health Maintenance |
10 | | Organization's profitable or unprofitable experience
with |
11 | | respect to the group or other enrollment unit for the |
12 | | period (and, for
purposes of a refund or additional |
13 | | premium, the profitable or unprofitable
experience shall |
14 | | be calculated taking into account a pro rata share of the
|
15 | | Health Maintenance Organization's administrative and |
16 | | marketing expenses, but
shall not include any refund to be |
17 | | made or additional premium to be paid
pursuant to this |
18 | | subsection (f)). The Health Maintenance Organization and |
19 | | the
group or enrollment unit may agree that the profitable |
20 | | or unprofitable
experience may be calculated taking into |
21 | | account the refund period and the
immediately preceding 2 |
22 | | plan years.
|
23 | | The Health Maintenance Organization shall include a |
24 | | statement in the
evidence of coverage issued to each enrollee |
25 | | describing the possibility of a
refund or additional premium, |
26 | | and upon request of any group or enrollment unit,
provide to |
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1 | | the group or enrollment unit a description of the method used |
2 | | to
calculate (1) the Health Maintenance Organization's |
3 | | profitable experience with
respect to the group or enrollment |
4 | | unit and the resulting refund to the group
or enrollment unit |
5 | | or (2) the Health Maintenance Organization's unprofitable
|
6 | | experience with respect to the group or enrollment unit and the |
7 | | resulting
additional premium to be paid by the group or |
8 | | enrollment unit.
|
9 | | In no event shall the Illinois Health Maintenance |
10 | | Organization
Guaranty Association be liable to pay any |
11 | | contractual obligation of an
insolvent organization to pay any |
12 | | refund authorized under this Section.
|
13 | | (g) Rulemaking authority to implement Public Act 95-1045, |
14 | | if any, is conditioned on the rules being adopted in accordance |
15 | | with all provisions of the Illinois Administrative Procedure |
16 | | Act and all rules and procedures of the Joint Committee on |
17 | | Administrative Rules; any purported rule not so adopted, for |
18 | | whatever reason, is unauthorized. |
19 | | (Source: P.A. 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; |
20 | | 96-833, eff. 6-1-10; 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; |
21 | | 97-343, eff. 1-1-12; 97-437, eff. 8-18-11; 97-486, eff. 1-1-12; |
22 | | 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813, eff. |
23 | | 7-13-12.) |
24 | | Section 35. The Limited Health Service Organization Act is |
25 | | amended by changing Section 4003 as follows:
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1 | | (215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
|
2 | | Sec. 4003. Illinois Insurance Code provisions. Limited |
3 | | health service
organizations shall be subject to the provisions |
4 | | of Sections 133, 134, 136, 137, 139,
140, 141.1, 141.2, 141.3, |
5 | | 143, 143c, 147, 148, 149, 151, 152, 153, 154, 154.5,
154.6, |
6 | | 154.7, 154.8, 155.04, 155.37, 355.2, 355.3, 356v, 356z.10, |
7 | | 356z.21, 356z.22, 368a, 401, 401.1,
402,
403, 403A, 408,
408.2, |
8 | | 409, 412, 444, and 444.1 and Articles IIA, VIII 1/2, XII, XII |
9 | | 1/2,
XIII,
XIII 1/2, XXV, and XXVI of the Illinois Insurance |
10 | | Code. For purposes of the
Illinois Insurance Code, except for |
11 | | Sections 444 and 444.1 and Articles XIII
and XIII 1/2, limited |
12 | | health service organizations in the following categories
are |
13 | | deemed to be domestic companies:
|
14 | | (1) a corporation under the laws of this State; or
|
15 | | (2) a corporation organized under the laws of another |
16 | | state, 30% of more
of the enrollees of which are residents |
17 | | of this State, except a corporation
subject to |
18 | | substantially the same requirements in its state of |
19 | | organization as
is a domestic company under Article VIII |
20 | | 1/2 of the Illinois Insurance Code.
|
21 | | (Source: P.A. 97-486, eff. 1-1-12; 97-592, 1-1-12; 97-805, eff. |
22 | | 1-1-13; 97-813, eff. 7-13-12.)
|
23 | | Section 40. The Voluntary Health Services Plans Act is |
24 | | amended by changing Section 10 as follows:
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1 | | (215 ILCS 165/10) (from Ch. 32, par. 604)
|
2 | | Sec. 10. Application of Insurance Code provisions. Health |
3 | | services
plan corporations and all persons interested therein |
4 | | or dealing therewith
shall be subject to the provisions of |
5 | | Articles IIA and XII 1/2 and Sections
3.1, 133, 136, 139, 140, |
6 | | 143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 356g, |
7 | | 356g.5, 356g.5-1, 356r, 356t, 356u, 356v,
356w, 356x, 356y, |
8 | | 356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
|
9 | | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18, |
10 | | 356z.19, 356z.21, 356z.22, 364.01, 367.2, 368a, 401, 401.1,
|
11 | | 402,
403, 403A, 408,
408.2, and 412, and paragraphs (7) and |
12 | | (15) of Section 367 of the Illinois
Insurance Code.
|
13 | | Rulemaking authority to implement Public Act 95-1045, if |
14 | | any, is conditioned on the rules being adopted in accordance |
15 | | with all provisions of the Illinois Administrative Procedure |
16 | | Act and all rules and procedures of the Joint Committee on |
17 | | Administrative Rules; any purported rule not so adopted, for |
18 | | whatever reason, is unauthorized. |
19 | | (Source: P.A. 96-328, eff. 8-11-09; 96-833, eff. 6-1-10; |
20 | | 96-1000, eff. 7-2-10; 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; |
21 | | 97-486, eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; |
22 | | 97-813, eff. 7-13-12.)".
|