Bill Text: IL HB3974 | 2023-2024 | 103rd General Assembly | Introduced

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Bill Title: Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of the amendatory Act shall cover charges incurred and services provided for outpatient and inpatient care in conjunction with services that are provided to a covered individual related to the diagnosis and treatment of a congenital anomaly or birth defect. Provides that the required coverage includes any service to functionally improve, repair, or restore any body part involving the cranial facial area that is medically necessary to achieve normal function or appearance. Provides that any coverage provided may be subject to coverage limits, such as pre-authorization or pre-certification, as required by the plan or issuer that are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan. Provides that the coverage does not apply to a policy that covers only dental care. Defines "treatment". Effective January 1, 2024.

Spectrum: Partisan Bill (Democrat 1-0)

Status: (Introduced) 2023-02-17 - Referred to Rules Committee [HB3974 Detail]

Download: Illinois-2023-HB3974-Introduced.html

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103RD GENERAL ASSEMBLY State of Illinois 2023 and 2024 HB3974 Introduced , by Rep. Joyce Mason SYNOPSIS AS INTRODUCED:
215 ILCS 5/356z.61 new
Amends the Illinois Insurance Code. Provides that an individual or group policy of accident and health insurance amended, delivered, issued, or renewed after the effective date of the amendatory Act shall cover charges incurred and services provided for outpatient and inpatient care in conjunction with services that are provided to a covered individual related to the diagnosis and treatment of a congenital anomaly or birth defect. Provides that the required coverage includes any service to functionally improve, repair, or restore any body part involving the cranial facial area that is medically necessary to achieve normal function or appearance. Provides that any coverage provided may be subject to coverage limits, such as pre-authorization or pre-certification, as required by the plan or issuer that are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the plan. Provides that the coverage does not apply to a policy that covers only dental care. Defines "treatment". Effective January 1, 2024.
LRB103 29802 BMS 56209 b
A BILL FOR
HB3974 LRB103 29802 BMS 56209 b
AN ACT concerning regulation.
Be it enacted by the People of the State of Illinois,
represented in the General Assembly:
Section 5. The Illinois Insurance Code is amended by
adding Section 356z.61 as follows:
(215 ILCS 5/356z.61 new)
Sec. 356z.61. Coverage for congenital anomaly or birth
defect.
(a) An individual or group policy of accident and health
insurance amended, delivered, issued, or renewed after the
effective date of this amendatory Act of the 103rd General
Assembly shall cover charges incurred and services provided
for outpatient and inpatient care in conjunction with services
that are provided to a covered individual related to the
diagnosis and treatment of a congenital anomaly or birth
defect, including, but not limited to, cleft lip and cleft
palate.
(b) Coverage required under this Section includes any
services to functionally improve, repair, or restore a body
part involving the cranial facial area, including cleft lip
and cleft palate, that is medically necessary to achieve
normal function or appearance. Any coverage provided may be
subject to coverage limits, such as pre-authorization or

HB3974 - 2 - LRB103 29802 BMS 56209 b
pre-certification, as required by the plan or issuer that are
no more restrictive than the predominant treatment limitations
applied to substantially all medical and surgical benefits
covered by the plan.
(c) As used in this Section, "treatment" includes
inpatient and outpatient care and services performed to
improve or restore body function, or performed to approximate
a normal appearance, due to a congenital anomaly, such as
cleft lip or cleft palate, involving the cranial facial area
and includes treatment of gross abnormalities of the lip and
palate and any condition or illness that is related to or
developed as a result of cleft lip or cleft palate.
"Treatment" does not include cosmetic surgery performed to
reshape normal facial structure or to improve appearance or
self-esteem.
(d) Coverage shall include, but not be limited to,
expenses for the following services up to the age of 19:
(1) oral surgery of the lip, palate, jaw, and related
structures, including bone grafts;
(2) facial surgery of the lip, palate, jaw, nose, and
related structures, including bone grafts;
(3) prosthetic treatment and appliances and
prosthodontia, including obturators, speech appliances,
and feeding appliances;
(4) orthodontic treatment and appliances and
orthodontia;

HB3974 - 3 - LRB103 29802 BMS 56209 b
(5) preventative and restorative dentistry;
(6) otolaryngology treatment and management; and
(7) anesthetics provided by a dentist with a permit
provided under Section 8.1 of the Illinois Dental Practice
Act when performed in conjunction with the treatment
described in this Section.
Coverage shall not be denied solely on the grounds that
the treatment is for cosmetic purposes or is not for a
functional defect or impairment as provided in this Section.
(e) This Section does not apply to a policy that covers
only dental care.