Bill Text: IL HB1530 | 2011-2012 | 97th General Assembly | Amended
NOTE: There are more recent revisions of this legislation. Read Latest Draft
Bill Title: Amends the Illinois Insurance Code in the provisions concerning autism spectrum disorders, habilitative services for children, and mental and emotional disorders to provide that certain coverage provided under those respective provisions through a group or individual policy of accident and health insurance or managed care plan shall be subject to the parity requirements of the provision concerning mental health parity. Sets forth a provision concerning mental health parity. Provides that every insurer that amends, delivers, issues, or renews a group policy of accident and health insurance in the State providing coverage for hospital or medical treatment and for the treatment of mental, emotional, nervous, or substance use disorders or conditions shall ensure adherence to the provisions concerning financial requirements and treatment limitations. Sets forth provisions concerning aggregate lifetime and annual limits. Amends the Health Maintenance Organization Act to comport with the provision of the Illinois Insurance Code concerning mental health parity. Makes other changes. Effective immediately.
Spectrum: Strong Partisan Bill (Democrat 38-3)
Status: (Passed) 2011-08-18 - Public Act . . . . . . . . . 97-0437 [HB1530 Detail]
Download: Illinois-2011-HB1530-Amended.html
Bill Title: Amends the Illinois Insurance Code in the provisions concerning autism spectrum disorders, habilitative services for children, and mental and emotional disorders to provide that certain coverage provided under those respective provisions through a group or individual policy of accident and health insurance or managed care plan shall be subject to the parity requirements of the provision concerning mental health parity. Sets forth a provision concerning mental health parity. Provides that every insurer that amends, delivers, issues, or renews a group policy of accident and health insurance in the State providing coverage for hospital or medical treatment and for the treatment of mental, emotional, nervous, or substance use disorders or conditions shall ensure adherence to the provisions concerning financial requirements and treatment limitations. Sets forth provisions concerning aggregate lifetime and annual limits. Amends the Health Maintenance Organization Act to comport with the provision of the Illinois Insurance Code concerning mental health parity. Makes other changes. Effective immediately.
Spectrum: Strong Partisan Bill (Democrat 38-3)
Status: (Passed) 2011-08-18 - Public Act . . . . . . . . . 97-0437 [HB1530 Detail]
Download: Illinois-2011-HB1530-Amended.html
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1 | AMENDMENT TO HOUSE BILL 1530
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2 | AMENDMENT NO. ______. Amend House Bill 1530 by replacing | ||||||
3 | everything after the enacting clause with the following:
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4 | "Section 5. The Illinois Insurance Code is amended by | ||||||
5 | changing Section 370c and by adding Section 370c.1 as follows:
| ||||||
6 | (215 ILCS 5/370c) (from Ch. 73, par. 982c)
| ||||||
7 | Sec. 370c. Mental and emotional disorders.
| ||||||
8 | (a) (1) On and after the effective date of this amendatory | ||||||
9 | Act of the 97th General Assembly Section ,
every insurer which | ||||||
10 | amends, delivers, issues, or renews delivers, issues for | ||||||
11 | delivery or renews or modifies
group accident and health A&H | ||||||
12 | policies providing coverage for hospital or medical treatment | ||||||
13 | or
services for illness on an expense-incurred basis shall | ||||||
14 | offer to the
applicant or group policyholder subject to the | ||||||
15 | insurer's insurers standards of
insurability, coverage for | ||||||
16 | reasonable and necessary treatment and services
for mental, |
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| |||||||
1 | emotional or nervous disorders or conditions, other than | ||||||
2 | serious
mental illnesses as defined in item (2) of subsection | ||||||
3 | (b), consistent with the parity requirements of Section 370c.1 | ||||||
4 | of this Code up to the limits
provided in the policy for other | ||||||
5 | disorders or conditions, except (i) the
insured may be required | ||||||
6 | to pay up to 50% of expenses incurred as a result
of the | ||||||
7 | treatment or services, and (ii) the annual benefit limit may be
| ||||||
8 | limited to the lesser of $10,000 or 25% of the lifetime policy | ||||||
9 | limit .
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10 | (2) Each insured that is covered for mental, emotional , or | ||||||
11 | nervous , or substance use
disorders or conditions shall be free | ||||||
12 | to select the physician licensed to
practice medicine in all | ||||||
13 | its branches, licensed clinical psychologist,
licensed | ||||||
14 | clinical social worker, licensed clinical professional | ||||||
15 | counselor, or licensed marriage and family therapist , licensed | ||||||
16 | speech-language pathologist, or other licensed or certified | ||||||
17 | professional at a program licensed pursuant to the Illinois | ||||||
18 | Alcoholism and Other Drug Abuse and Dependency Act of
his | ||||||
19 | choice to treat such disorders, and
the insurer shall pay the | ||||||
20 | covered charges of such physician licensed to
practice medicine | ||||||
21 | in all its branches, licensed clinical psychologist,
licensed | ||||||
22 | clinical social worker, licensed clinical professional | ||||||
23 | counselor, or licensed marriage and family therapist , licensed | ||||||
24 | speech-language pathologist, or other licensed or certified | ||||||
25 | professional at a program licensed pursuant to the Illinois | ||||||
26 | Alcoholism and Other Drug Abuse and Dependency Act up
to the |
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1 | limits of coverage, provided (i)
the disorder or condition | ||||||
2 | treated is covered by the policy, and (ii) the
physician, | ||||||
3 | licensed psychologist, licensed clinical social worker, | ||||||
4 | licensed
clinical professional counselor, or licensed marriage | ||||||
5 | and family therapist , licensed speech-language pathologist, or | ||||||
6 | other licensed or certified professional at a program licensed | ||||||
7 | pursuant to the Illinois Alcoholism and Other Drug Abuse and | ||||||
8 | Dependency Act is
authorized to provide said services under the | ||||||
9 | statutes of this State and in
accordance with accepted | ||||||
10 | principles of his profession.
| ||||||
11 | (3) Insofar as this Section applies solely to licensed | ||||||
12 | clinical social
workers, licensed clinical professional | ||||||
13 | counselors, and licensed marriage and family therapists, | ||||||
14 | licensed speech-language pathologist, and other licensed or | ||||||
15 | certified professionals at programs licensed pursuant to the | ||||||
16 | Illinois Alcoholism and Other Drug Abuse and Dependency Act, | ||||||
17 | those persons who may
provide services to individuals shall do | ||||||
18 | so
after the licensed clinical social worker, licensed clinical | ||||||
19 | professional
counselor, or licensed marriage and family | ||||||
20 | therapist , licensed speech-language pathologist, or other | ||||||
21 | licensed or certified professional at a program licensed | ||||||
22 | pursuant to the Illinois Alcoholism and Other Drug Abuse and | ||||||
23 | Dependency Act has informed the patient of the
desirability of | ||||||
24 | the patient conferring with the patient's primary care
| ||||||
25 | physician and the licensed clinical social worker, licensed | ||||||
26 | clinical
professional counselor, or licensed marriage and |
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1 | family therapist , licensed speech-language pathologist, or | ||||||
2 | other licensed or certified professional at a program licensed | ||||||
3 | pursuant to the Illinois Alcoholism and Other Drug Abuse and | ||||||
4 | Dependency Act has
provided written
notification to the | ||||||
5 | patient's primary care physician, if any, that services
are | ||||||
6 | being provided to the patient. That notification may, however, | ||||||
7 | be
waived by the patient on a written form. Those forms shall | ||||||
8 | be retained by
the licensed clinical social worker, licensed | ||||||
9 | clinical professional counselor, or licensed marriage and | ||||||
10 | family therapist , licensed speech-language pathologist, or | ||||||
11 | other licensed or certified professional at a program licensed | ||||||
12 | pursuant to the Illinois Alcoholism and Other Drug Abuse and | ||||||
13 | Dependency Act
for a period of not less than 5 years.
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14 | (b) (1) An insurer that provides coverage for hospital or | ||||||
15 | medical
expenses under a group policy of accident and health | ||||||
16 | insurance or
health care plan amended, delivered, issued, or | ||||||
17 | renewed on or after the effective
date of this amendatory Act | ||||||
18 | of the 97th 92nd General Assembly shall provide coverage
under | ||||||
19 | the policy for treatment of serious mental illness and | ||||||
20 | substance use disorders consistent with the parity | ||||||
21 | requirements of Section 370c.1 of this Code under the same | ||||||
22 | terms
and conditions as coverage for hospital or medical | ||||||
23 | expenses related to other
illnesses and diseases. The coverage | ||||||
24 | required under this Section must provide
for same durational | ||||||
25 | limits, amount limits, deductibles, and co-insurance
| ||||||
26 | requirements for serious mental illness as are provided for |
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1 | other illnesses
and diseases . This subsection does not apply to | ||||||
2 | any group policy of accident and health insurance or health | ||||||
3 | care plan for any plan year of a small employer as defined in | ||||||
4 | Section 5 of the Illinois Health Insurance Portability and | ||||||
5 | Accountability Act coverage provided to
employees by employers | ||||||
6 | who have 50 or fewer employees .
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7 | (2) "Serious mental illness" means the following | ||||||
8 | psychiatric illnesses as
defined in the most current edition of | ||||||
9 | the Diagnostic and Statistical Manual
(DSM) published by the | ||||||
10 | American Psychiatric Association:
| ||||||
11 | (A) schizophrenia;
| ||||||
12 | (B) paranoid and other psychotic disorders;
| ||||||
13 | (C) bipolar disorders (hypomanic, manic, depressive, | ||||||
14 | and mixed);
| ||||||
15 | (D) major depressive disorders (single episode or | ||||||
16 | recurrent);
| ||||||
17 | (E) schizoaffective disorders (bipolar or depressive);
| ||||||
18 | (F) pervasive developmental disorders;
| ||||||
19 | (G) obsessive-compulsive disorders;
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20 | (H) depression in childhood and adolescence;
| ||||||
21 | (I) panic disorder; | ||||||
22 | (J) post-traumatic stress disorders (acute, chronic, | ||||||
23 | or with delayed onset); and
| ||||||
24 | (K) anorexia nervosa and bulimia nervosa. | ||||||
25 | (2.5) "Substance use disorder" means the following mental | ||||||
26 | disorders as defined in the most current edition of the |
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| |||||||
1 | Diagnostic and Statistical Manual (DSM) published by the | ||||||
2 | American Psychiatric Association: | ||||||
3 | (A) substance abuse disorders; | ||||||
4 | (B) substance dependence disorders; and | ||||||
5 | (C) substance induced disorders. | ||||||
6 | (3) Unless otherwise prohibited by federal law and | ||||||
7 | consistent with the parity requirements of Section 370c.1 of | ||||||
8 | this Code, Upon request of the reimbursing insurer, a provider | ||||||
9 | of treatment of
serious mental illness or substance use | ||||||
10 | disorder shall furnish medical records or other necessary data
| ||||||
11 | that substantiate that initial or continued treatment is at all | ||||||
12 | times medically
necessary. An insurer shall provide a mechanism | ||||||
13 | for the timely review by a
provider holding the same license | ||||||
14 | and practicing in the same specialty as the
patient's provider, | ||||||
15 | who is unaffiliated with the insurer, jointly selected by
the | ||||||
16 | patient (or the patient's next of kin or legal representative | ||||||
17 | if the
patient is unable to act for himself or herself), the | ||||||
18 | patient's provider, and
the insurer in the event of a dispute | ||||||
19 | between the insurer and patient's
provider regarding the | ||||||
20 | medical necessity of a treatment proposed by a patient's
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21 | provider. If the reviewing provider determines the treatment to | ||||||
22 | be medically
necessary, the insurer shall provide | ||||||
23 | reimbursement for the treatment. Future
contractual or | ||||||
24 | employment actions by the insurer regarding the patient's
| ||||||
25 | provider may not be based on the provider's participation in | ||||||
26 | this procedure.
Nothing prevents
the insured from agreeing in |
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1 | writing to continue treatment at his or her
expense. When | ||||||
2 | making a determination of the medical necessity for a treatment
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3 | modality for serious serous mental illness or substance use | ||||||
4 | disorder , an insurer must make the determination in a
manner | ||||||
5 | that is consistent with the manner used to make that | ||||||
6 | determination with
respect to other diseases or illnesses | ||||||
7 | covered under the policy, including an
appeals process. Medical | ||||||
8 | necessity determinations for substance use disorders shall be | ||||||
9 | made in accordance with appropriate patient placement criteria | ||||||
10 | established by the American Society of Addiction Medicine.
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11 | (4) A group health benefit plan amended, delivered, issued, | ||||||
12 | or renewed on or after the effective date of this amendatory | ||||||
13 | Act of the 97th General Assembly :
| ||||||
14 | (A) shall provide coverage based upon medical | ||||||
15 | necessity for the following
treatment of mental illness and | ||||||
16 | substance use disorders consistent with the parity | ||||||
17 | requirements of Section 370c.1 of this Code; provided, | ||||||
18 | however, that in each calendar year coverage shall not be | ||||||
19 | less than the following :
| ||||||
20 | (i) 45 days of inpatient treatment; and
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21 | (ii) beginning on June 26, 2006 (the effective date | ||||||
22 | of Public Act 94-921), 60 visits for outpatient | ||||||
23 | treatment including group and individual
outpatient | ||||||
24 | treatment; and | ||||||
25 | (iii) for plans or policies delivered, issued for | ||||||
26 | delivery, renewed, or modified after January 1, 2007 |
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1 | (the effective date of Public Act 94-906),
20 | ||||||
2 | additional outpatient visits for speech therapy for | ||||||
3 | treatment of pervasive developmental disorders that | ||||||
4 | will be in addition to speech therapy provided pursuant | ||||||
5 | to item (ii) of this subparagraph (A); and
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6 | (B) may not include a lifetime limit on the number of | ||||||
7 | days of inpatient
treatment or the number of outpatient | ||||||
8 | visits covered under the plan . ; and
| ||||||
9 | (C) (Blank). shall include the same amount limits, | ||||||
10 | deductibles, copayments, and
coinsurance factors for | ||||||
11 | serious mental illness as for physical illness.
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12 | (5) An issuer of a group health benefit plan may not count | ||||||
13 | toward the number
of outpatient visits required to be covered | ||||||
14 | under this Section an outpatient
visit for the purpose of | ||||||
15 | medication management and shall cover the outpatient
visits | ||||||
16 | under the same terms and conditions as it covers outpatient | ||||||
17 | visits for
the treatment of physical illness.
| ||||||
18 | (6) An issuer of a group health benefit
plan may provide or | ||||||
19 | offer coverage required under this Section through a
managed | ||||||
20 | care plan.
| ||||||
21 | (7) (Blank). This Section shall not be interpreted to | ||||||
22 | require a group health benefit
plan to provide coverage for | ||||||
23 | treatment of:
| ||||||
24 | (A) an addiction to a controlled substance or cannabis | ||||||
25 | that is used in
violation of law; or
| ||||||
26 | (B) mental illness resulting from the use of a |
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1 | controlled substance or
cannabis in violation of law.
| ||||||
2 | (8)
(Blank).
| ||||||
3 | (9) With respect to substance use disorders, coverage for | ||||||
4 | inpatient treatment shall include coverage for treatment in a | ||||||
5 | residential treatment center licensed by the Department of | ||||||
6 | Public Health or the Department of Human Services, Division of | ||||||
7 | Alcoholism and Substance Abuse. | ||||||
8 | (c) This Section shall not be interpreted to require | ||||||
9 | coverage for speech therapy or other habilitative services for | ||||||
10 | those individuals covered under Section 356z.15
of this Code. | ||||||
11 | (Source: P.A. 95-331, eff. 8-21-07; 95-972, eff. 9-22-08; | ||||||
12 | 95-973, eff. 1-1-09; 95-1049, eff. 1-1-10; 96-328, eff. | ||||||
13 | 8-11-09; 96-1000, eff. 7-2-10.)
| ||||||
14 | (215 ILCS 5/370c.1 new) | ||||||
15 | Sec. 370c.1. Mental health parity. | ||||||
16 | (a) On and after the effective date of this amendatory Act | ||||||
17 | of the 97th General Assembly, every insurer that amends, | ||||||
18 | delivers, issues, or renews a group policy of accident and | ||||||
19 | health insurance in this State providing coverage for hospital | ||||||
20 | or medical treatment and for the treatment of mental, | ||||||
21 | emotional, nervous, or substance use disorders or conditions | ||||||
22 | shall ensure that: | ||||||
23 | (1) the financial requirements applicable to such | ||||||
24 | mental, emotional, nervous, or substance use disorder or | ||||||
25 | condition benefits are no more restrictive than the |
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| |||||||
1 | predominant financial requirements applied to | ||||||
2 | substantially all hospital and medical benefits covered by | ||||||
3 | the policy and that there are no separate cost-sharing | ||||||
4 | requirements that are applicable only with respect to | ||||||
5 | mental, emotional, nervous, or substance use disorder or | ||||||
6 | condition benefits; and | ||||||
7 | (2) the treatment limitations applicable to such | ||||||
8 | mental, emotional, nervous, or substance use disorder or | ||||||
9 | condition benefits are no more restrictive than the | ||||||
10 | predominant treatment limitations applied to substantially | ||||||
11 | all hospital and medical benefits covered by the policy and | ||||||
12 | that there are no separate treatment limitations that are | ||||||
13 | applicable only with respect to mental, emotional, | ||||||
14 | nervous, or substance use disorder or condition benefits. | ||||||
15 | (b) The following provisions shall apply concerning | ||||||
16 | aggregate lifetime limits: | ||||||
17 | (1) In the case of a group policy of accident and | ||||||
18 | health insurance amended, delivered, issued, or renewed in | ||||||
19 | this State on or after the effective date of this | ||||||
20 | amendatory Act of the 97th General Assembly that provides | ||||||
21 | coverage for hospital or medical treatment and for the | ||||||
22 | treatment of mental, emotional, nervous, or substance use | ||||||
23 | disorders or conditions the following provisions shall | ||||||
24 | apply: | ||||||
25 | (A) if the policy does not include an aggregate | ||||||
26 | lifetime limit on substantially all hospital and |
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1 | medical benefits, then the policy may not impose any | ||||||
2 | aggregate lifetime limit on mental, emotional, | ||||||
3 | nervous, or substance use disorder or condition | ||||||
4 | benefits; or | ||||||
5 | (B) if the policy includes an aggregate lifetime | ||||||
6 | limit on substantially all hospital and medical | ||||||
7 | benefits (in this subsection referred to as the | ||||||
8 | "applicable lifetime limit"), then the policy shall | ||||||
9 | either: | ||||||
10 | (i) apply the applicable lifetime limit both | ||||||
11 | to the hospital and medical benefits to which it | ||||||
12 | otherwise would apply and to mental, emotional, | ||||||
13 | nervous, or substance use disorder or condition | ||||||
14 | benefits and not distinguish in the application of | ||||||
15 | the limit between the hospital and medical | ||||||
16 | benefits and mental, emotional, nervous, or | ||||||
17 | substance use disorder or condition benefits; or | ||||||
18 | (ii) not include any aggregate lifetime limit | ||||||
19 | on mental, emotional, nervous, or substance use | ||||||
20 | disorder or condition benefits that is less than | ||||||
21 | the applicable lifetime limit. | ||||||
22 | (2) In the case of a policy that is not described in | ||||||
23 | paragraph (1) of subsection (b) of this Section and that | ||||||
24 | includes no or different aggregate lifetime limits on | ||||||
25 | different categories of hospital and medical benefits, the | ||||||
26 | Director shall establish rules under which subparagraph |
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1 | (B) of paragraph (1) of subsection (b) of this Section is | ||||||
2 | applied to such policy with respect to mental, emotional, | ||||||
3 | nervous, or substance use disorder or condition benefits by | ||||||
4 | substituting for the applicable lifetime limit an average | ||||||
5 | aggregate lifetime limit that is computed taking into | ||||||
6 | account the weighted average of the aggregate lifetime | ||||||
7 | limits applicable to such categories. | ||||||
8 | (c) The following provisions shall apply concerning annual | ||||||
9 | limits: | ||||||
10 | (1) In the case of a group policy of accident and | ||||||
11 | health insurance amended, delivered, issued, or renewed in | ||||||
12 | this State on or after the effective date of this | ||||||
13 | amendatory Act of the 97th General Assembly that provides | ||||||
14 | coverage for hospital or medical treatment and for the | ||||||
15 | treatment of mental, emotional, nervous, or substance use | ||||||
16 | disorders or conditions the following provisions shall | ||||||
17 | apply: | ||||||
18 | (A) if the policy does not include an annual limit | ||||||
19 | on substantially all hospital and medical benefits, | ||||||
20 | then the policy may not impose any annual limits on | ||||||
21 | mental, emotional, nervous, or substance use disorder | ||||||
22 | or condition benefits; or | ||||||
23 | (B) if the policy includes an annual limit on | ||||||
24 | substantially all hospital and medical benefits (in | ||||||
25 | this subsection referred to as the "applicable annual | ||||||
26 | limit"), then the policy shall either: |
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1 | (i) apply the applicable annual limit both to | ||||||
2 | the hospital and medical benefits to which it | ||||||
3 | otherwise would apply and to mental, emotional, | ||||||
4 | nervous, or substance use disorder or condition | ||||||
5 | benefits and not distinguish in the application of | ||||||
6 | the limit between the hospital and medical | ||||||
7 | benefits and mental, emotional, nervous, or | ||||||
8 | substance use disorder or condition benefits; or | ||||||
9 | (ii) not include any annual limit on mental, | ||||||
10 | emotional, nervous, or substance use disorder or | ||||||
11 | condition benefits that is less than the | ||||||
12 | applicable annual limit. | ||||||
13 | (2) In the case of a policy that is not described in | ||||||
14 | paragraph (1) of subsection (c) of this Section and that | ||||||
15 | includes no or different annual limits on different | ||||||
16 | categories of hospital and medical benefits, the Director | ||||||
17 | shall establish rules under which subparagraph (B) of | ||||||
18 | paragraph (1) of subsection (c) of this Section is applied | ||||||
19 | to such policy with respect to mental, emotional, nervous, | ||||||
20 | or substance use disorder or condition benefits by | ||||||
21 | substituting for the applicable annual limit an average | ||||||
22 | annual limit that is computed taking into account the | ||||||
23 | weighted average of the annual limits applicable to such | ||||||
24 | categories. | ||||||
25 | (d) This Section shall be interpreted in a manner | ||||||
26 | consistent with the interim final regulations promulgated by |
| |||||||
| |||||||
1 | the U.S. Department of Health and Human Services at 75 FR 5410, | ||||||
2 | including the prohibition against applying a cumulative | ||||||
3 | financial requirement or cumulative quantitative treatment | ||||||
4 | limitation for mental, emotional, nervous, or substance use | ||||||
5 | disorder benefits that accumulates separately from any | ||||||
6 | cumulative financial requirement or cumulative quantitative | ||||||
7 | treatment limitation established for hospital and medical | ||||||
8 | benefits in the same classification. | ||||||
9 | (e) The provisions of subsections (b) and (c) of this | ||||||
10 | Section shall not be interpreted to allow the use of lifetime | ||||||
11 | or annual limits otherwise prohibited by State or federal law. | ||||||
12 | (f) This Section shall not apply to individual health | ||||||
13 | insurance coverage as defined in Section 5 of the Illinois | ||||||
14 | Health Insurance Portability and Accountability Act. | ||||||
15 | (g) As used in this Section: | ||||||
16 | "Financial requirement" includes deductibles, copayments, | ||||||
17 | coinsurance, and out-of-pocket maximums, but does not include | ||||||
18 | an aggregate lifetime limit or an annual limit subject to | ||||||
19 | subsections (b) and (c). | ||||||
20 | "Treatment limitation" includes limits on benefits based | ||||||
21 | on the frequency of treatment, number of visits, days of | ||||||
22 | coverage, days in a waiting period, or other similar limits on | ||||||
23 | the scope or duration of treatment. "Treatment limitation" | ||||||
24 | includes both quantitative treatment limitations, which are | ||||||
25 | expressed numerically (such as 50 outpatient visits per year), | ||||||
26 | and nonquantitative treatment limitations, which otherwise |
| |||||||
| |||||||
1 | limit the scope or duration of treatment. A permanent exclusion | ||||||
2 | of all benefits for a particular condition or disorder shall | ||||||
3 | not be considered a treatment limitation.
| ||||||
4 | Section 10. The Health Maintenance Organization Act is | ||||||
5 | amended by changing Section 5-3 as follows:
| ||||||
6 | (215 ILCS 125/5-3) (from Ch. 111 1/2, par. 1411.2)
| ||||||
7 | Sec. 5-3. Insurance Code provisions.
| ||||||
8 | (a) Health Maintenance Organizations
shall be subject to | ||||||
9 | the provisions of Sections 133, 134, 137, 140, 141.1,
141.2, | ||||||
10 | 141.3, 143, 143c, 147, 148, 149, 151,
152, 153, 154, 154.5, | ||||||
11 | 154.6,
154.7, 154.8, 155.04, 355.2, 356g.5-1, 356m, 356v, 356w, | ||||||
12 | 356x, 356y,
356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9, | ||||||
13 | 356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.17, | ||||||
14 | 356z.18, 364.01, 367.2, 367.2-5, 367i, 368a, 368b, 368c, 368d, | ||||||
15 | 368e, 370c, 370c.1,
401, 401.1, 402, 403, 403A,
408, 408.2, | ||||||
16 | 409, 412, 444,
and
444.1,
paragraph (c) of subsection (2) of | ||||||
17 | Section 367, and Articles IIA, VIII 1/2,
XII,
XII 1/2, XIII, | ||||||
18 | XIII 1/2, XXV, and XXVI of the Illinois Insurance Code.
| ||||||
19 | (b) For purposes of the Illinois Insurance Code, except for | ||||||
20 | Sections 444
and 444.1 and Articles XIII and XIII 1/2, Health | ||||||
21 | Maintenance Organizations in
the following categories are | ||||||
22 | deemed to be "domestic companies":
| ||||||
23 | (1) a corporation authorized under the
Dental Service | ||||||
24 | Plan Act or the Voluntary Health Services Plans Act;
|
| |||||||
| |||||||
1 | (2) a corporation organized under the laws of this | ||||||
2 | State; or
| ||||||
3 | (3) a corporation organized under the laws of another | ||||||
4 | state, 30% or more
of the enrollees of which are residents | ||||||
5 | of this State, except a
corporation subject to | ||||||
6 | substantially the same requirements in its state of
| ||||||
7 | organization as is a "domestic company" under Article VIII | ||||||
8 | 1/2 of the
Illinois Insurance Code.
| ||||||
9 | (c) In considering the merger, consolidation, or other | ||||||
10 | acquisition of
control of a Health Maintenance Organization | ||||||
11 | pursuant to Article VIII 1/2
of the Illinois Insurance Code,
| ||||||
12 | (1) the Director shall give primary consideration to | ||||||
13 | the continuation of
benefits to enrollees and the financial | ||||||
14 | conditions of the acquired Health
Maintenance Organization | ||||||
15 | after the merger, consolidation, or other
acquisition of | ||||||
16 | control takes effect;
| ||||||
17 | (2)(i) the criteria specified in subsection (1)(b) of | ||||||
18 | Section 131.8 of
the Illinois Insurance Code shall not | ||||||
19 | apply and (ii) the Director, in making
his determination | ||||||
20 | with respect to the merger, consolidation, or other
| ||||||
21 | acquisition of control, need not take into account the | ||||||
22 | effect on
competition of the merger, consolidation, or | ||||||
23 | other acquisition of control;
| ||||||
24 | (3) the Director shall have the power to require the | ||||||
25 | following
information:
| ||||||
26 | (A) certification by an independent actuary of the |
| |||||||
| |||||||
1 | adequacy
of the reserves of the Health Maintenance | ||||||
2 | Organization sought to be acquired;
| ||||||
3 | (B) pro forma financial statements reflecting the | ||||||
4 | combined balance
sheets of the acquiring company and | ||||||
5 | the Health Maintenance Organization sought
to be | ||||||
6 | acquired as of the end of the preceding year and as of | ||||||
7 | a date 90 days
prior to the acquisition, as well as pro | ||||||
8 | forma financial statements
reflecting projected | ||||||
9 | combined operation for a period of 2 years;
| ||||||
10 | (C) a pro forma business plan detailing an | ||||||
11 | acquiring party's plans with
respect to the operation | ||||||
12 | of the Health Maintenance Organization sought to
be | ||||||
13 | acquired for a period of not less than 3 years; and
| ||||||
14 | (D) such other information as the Director shall | ||||||
15 | require.
| ||||||
16 | (d) The provisions of Article VIII 1/2 of the Illinois | ||||||
17 | Insurance Code
and this Section 5-3 shall apply to the sale by | ||||||
18 | any health maintenance
organization of greater than 10% of its
| ||||||
19 | enrollee population (including without limitation the health | ||||||
20 | maintenance
organization's right, title, and interest in and to | ||||||
21 | its health care
certificates).
| ||||||
22 | (e) In considering any management contract or service | ||||||
23 | agreement subject
to Section 141.1 of the Illinois Insurance | ||||||
24 | Code, the Director (i) shall, in
addition to the criteria | ||||||
25 | specified in Section 141.2 of the Illinois
Insurance Code, take | ||||||
26 | into account the effect of the management contract or
service |
| |||||||
| |||||||
1 | agreement on the continuation of benefits to enrollees and the
| ||||||
2 | financial condition of the health maintenance organization to | ||||||
3 | be managed or
serviced, and (ii) need not take into account the | ||||||
4 | effect of the management
contract or service agreement on | ||||||
5 | competition.
| ||||||
6 | (f) Except for small employer groups as defined in the | ||||||
7 | Small Employer
Rating, Renewability and Portability Health | ||||||
8 | Insurance Act and except for
medicare supplement policies as | ||||||
9 | defined in Section 363 of the Illinois
Insurance Code, a Health | ||||||
10 | Maintenance Organization may by contract agree with a
group or | ||||||
11 | other enrollment unit to effect refunds or charge additional | ||||||
12 | premiums
under the following terms and conditions:
| ||||||
13 | (i) the amount of, and other terms and conditions with | ||||||
14 | respect to, the
refund or additional premium are set forth | ||||||
15 | in the group or enrollment unit
contract agreed in advance | ||||||
16 | of the period for which a refund is to be paid or
| ||||||
17 | additional premium is to be charged (which period shall not | ||||||
18 | be less than one
year); and
| ||||||
19 | (ii) the amount of the refund or additional premium | ||||||
20 | shall not exceed 20%
of the Health Maintenance | ||||||
21 | Organization's profitable or unprofitable experience
with | ||||||
22 | respect to the group or other enrollment unit for the | ||||||
23 | period (and, for
purposes of a refund or additional | ||||||
24 | premium, the profitable or unprofitable
experience shall | ||||||
25 | be calculated taking into account a pro rata share of the
| ||||||
26 | Health Maintenance Organization's administrative and |
| |||||||
| |||||||
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 | (g) Rulemaking authority to implement Public Act 95-1045, | ||||||
25 | if any, is conditioned on the rules being adopted in accordance | ||||||
26 | with all provisions of the Illinois Administrative Procedure |
| |||||||
| |||||||
1 | Act and all rules and procedures of the Joint Committee on | ||||||
2 | Administrative Rules; any purported rule not so adopted, for | ||||||
3 | whatever reason, is unauthorized. | ||||||
4 | (Source: P.A. 95-422, eff. 8-24-07; 95-520, eff. 8-28-07; | ||||||
5 | 95-876, eff. 8-21-08; 95-958, eff. 6-1-09; 95-978, eff. 1-1-09; | ||||||
6 | 95-1005, eff. 12-12-08; 95-1045, eff. 3-27-09; 95-1049, eff. | ||||||
7 | 1-1-10; 96-328, eff. 8-11-09; 96-639, eff. 1-1-10; 96-833, eff. | ||||||
8 | 6-1-10; 96-1000, eff. 7-2-10.)
| ||||||
9 | Section 99. Effective date. This Act takes effect upon | ||||||
10 | becoming law.".
|