Bill Text: IL SB2807 | 2015-2016 | 99th General Assembly | Introduced

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Bill Title: Amends the Illinois Insurance Code. Provides that on and after the effective date of the amendatory Act, no insurer that amends, delivers, issues, or renews a group or individual policy of accident and health insurance or a qualified health plan offered through the health insurance marketplace shall: (1) provide or refer to a coverage determination as medically necessary in any publication, policy, contract or agreement, or explanation of benefits made by the policy or plan, or (2) provide or state in any way that treatment or services recommended by the insured or enrollees treating, consulting, ordering, or attending physician or health care provider is not medically necessary, and that doing so is an unfair and deceptive practice under the Code. Provides that nothing shall prohibit a health care benefit determination with respect to whether treatment or services are covered under the policy or plan. Amends the Managed Care Reform and Patient Rights Act to make similar changes for health care plans. Amends the State Employees Group Insurance Act of 1971, Counties Code, Illinois Municipal Code, School Code, Health Maintenance Organization Act, Limited Health Service Organization Act, Voluntary Health Services Plans Act, and Illinois Public Aide Code to make conforming changes.

Spectrum: Partisan Bill (Democrat 2-0)

Status: (Introduced - Dead) 2016-04-22 - Rule 3-9(a) / Re-referred to Assignments [SB2807 Detail]

Download: Illinois-2015-SB2807-Introduced.html

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99TH GENERAL ASSEMBLY State of Illinois 2015 and 2016 SB2807 Introduced 2/17/2016, by Sen. Linda Holmes SYNOPSIS AS INTRODUCED:
5 ILCS 375/6.11
55 ILCS 5/5-1069.3
65 ILCS 5/10-4-2.3
105 ILCS 5/10-22.3f
215 ILCS 5/2 from Ch. 73, par. 614
215 ILCS 5/356z.24 new
215 ILCS 130/4003 from Ch. 73, par. 1504-3
215 ILCS 134/10
215 ILCS 134/31 new
215 ILCS 165/10 from Ch. 32, par. 604
305 ILCS 5/5-16.8
Amends the Illinois Insurance Code. Provides that on and after the effective date of the amendatory Act, no insurer that amends, delivers, issues, or renews a group or individual policy of accident and health insurance or a qualified health plan offered through the health insurance marketplace shall: (1) provide or refer to a coverage determination as medically necessary in any publication, policy, contract or agreement, or explanation of benefits made by the policy or plan, or (2) provide or state in any way that treatment or services recommended by the insured or enrollees treating, consulting, ordering, or attending physician or health care provider is not medically necessary, and that doing so is an unfair and deceptive practice under the Code. Provides that nothing shall prohibit a health care benefit determination with respect to whether treatment or services are covered under the policy or plan. Amends the Managed Care Reform and Patient Rights Act to make similar changes for health care plans. Amends the State Employees Group Insurance Act of 1971, Counties Code, Illinois Municipal Code, School Code, Health Maintenance Organization Act, Limited Health Service Organization Act, Voluntary Health Services Plans Act, and Illinois Public Aide Code to make conforming changes.
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A BILL FOR
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AN ACT concerning regulation.
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,
356g.5, 356g.5-1, 356m, 356u, 356w, 356x, 356z.2, 356z.4,
356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
356z.14, 356z.15, 356z.17, and 356z.22 of the Illinois
Insurance Code. The program of health benefits must comply with
Sections 155.22a, 155.37, 355b, 356z.19, 356z.24, 370c, and
370c.1 of the Illinois Insurance Code.
Rulemaking authority to implement Public Act 95-1045, 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

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whatever reason, is unauthorized.
(Source: P.A. 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15;
99-480, eff. 9-9-15.)
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, 356g.5, 356g.5-1, 356u, 356w, 356x,
356z.6, 356z.8, 356z.9, 356z.10, 356z.11, 356z.12, 356z.13,
356z.14, 356z.15, and 356z.22 of the Illinois Insurance Code.
The coverage shall comply with Sections 155.22a, 355b, 356z.19,
356z.24, and 370c 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.
Rulemaking authority to implement Public Act 95-1045, if

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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.
(Source: P.A. 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15;
99-480, eff. 9-9-15.)
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, 356g.5,
356g.5-1, 356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.10,
356z.11, 356z.12, 356z.13, 356z.14, 356z.15, and 356z.22 of the
Illinois Insurance Code. The coverage shall comply with
Sections 155.22a, 355b, 356z.19, 356z.24, and 370c 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

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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.
Rulemaking authority to implement Public Act 95-1045, 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.
(Source: P.A. 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15;
99-480, eff. 9-9-15.)
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, 356g.5, 356g.5-1,
356u, 356w, 356x, 356z.6, 356z.8, 356z.9, 356z.11, 356z.12,
356z.13, 356z.14, 356z.15, and 356z.22 of the Illinois
Insurance Code. Insurance policies shall comply with Sections
Section 356z.19 and 356z.24 of the Illinois Insurance Code. The
coverage shall comply with Sections 155.22a and 355b of the

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Illinois Insurance Code.
Rulemaking authority to implement Public Act 95-1045, 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.
(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-813,
eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
Section 25. The Illinois Insurance Code is amended by
changing Section 2 and by adding Section 356z.24 as follows:
(215 ILCS 5/2) (from Ch. 73, par. 614)
Sec. 2. General definitions.
In this Code, unless the context otherwise requires,
(a) "Director" means the Director of Insurance.
(b) "Department" means the Department of Insurance.
(c) "State" or "State of the United States" includes the
District of Columbia and a territory or possession of the
United States.
(d) "Country" or "Foreign Country" includes a state,
province or political subdivision thereof.
(e) "Company" means an insurance or surety company and
shall be deemed to include a corporation, company, partnership,
association, society, order, individual or aggregation of

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individuals engaging in or proposing or attempting to engage in
any kind of insurance or surety business, including the
exchanging of reciprocal or inter-insurance contracts between
individuals, partnerships and corporations.
(f) "Domestic Company" means a company incorporated or
organized under the laws of this State.
(g) "Foreign Company" means a company incorporated or
organized under the laws of any state of the United States
other than this State.
(h) "Alien Company" means a company incorporated or
organized under the laws of any country other than the United
States.
(i) "Mutual Legal Reserve Life Company" means a mutual life
company issuing contracts without contingent liability on the
policyholder.
(j) "Assessment Legal Reserve Life Company" means a life
company issuing contracts providing for contingent liability
on the policyholder.
(k) "Reciprocal" includes Inter-Insurance Exchange.
(l) "Person" includes an individual, aggregation of
individuals, corporation, association and partnership.
(m) Personal pronouns include all genders, the singular
includes the plural and the plural includes the singular.
(n) "Policy" means an insurance policy or contract and
includes certificates of fraternal benefit societies,
assessment companies, mutual benefit associations, and burial

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societies.
(o) "Policyholder" means a holder of an insurance policy or
contract and includes holders of certificates of fraternal
benefit societies, assessment companies, mutual benefit
associations, and burial societies.
(p) "Articles of Incorporation" means the basic instrument
of an incorporated company and all amendments thereto and
includes "Charter," "Articles of Organization," "Articles of
Reorganization," "Articles of Association," and "Deed of
Settlement."
(q) "Officer" when used to refer to an officer of a company
includes an attorney-in-fact for a reciprocal or Lloyds.
(r) "Medically necessary" means that a treating,
consulting, ordering, or attending physician or health care
professional or provider recommended, ordered, or provided a
health care service, device, drug, or supply appropriate to the
evaluation and treatment of disease, condition, illness, or
injury and consistent with the applicable standard of care,
including the evaluation of experimental or investigational
services, procedures, drugs, or devices.
(Source: Laws 1937, p. 696.)
(215 ILCS 5/356z.24 new)
Sec. 356z.24. Medical necessity determinations. On and
after the effective date of this amendatory Act of the 99th
General Assembly, no insurer that amends, delivers, issues, or

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renews a group or individual policy of accident and health
insurance or a qualified health plan offered through the health
insurance marketplace in this State providing coverage for
hospital or any other health care service shall: (1) provide or
refer to a coverage determination as medically necessary in any
publication, policy, contract or agreement, or explanation of
benefits made by the policy or plan or (2) provide or state in
any way that treatment or services recommended by the insured
or enrollees treating, consulting, ordering, or attending
physician or health care provider is not medically necessary,
to do so shall be considered an unfair and deceptive practice
under this Code. Nothing in this Section shall prohibit a
health care benefit determination with respect to whether
treatment or services are covered under the policy or plan.
Section 30. The Limited Health Service Organization Act is
amended by changing Section 4003 as follows:
(215 ILCS 130/4003) (from Ch. 73, par. 1504-3)
Sec. 4003. Illinois Insurance Code provisions. Limited
health service organizations shall be subject to the provisions
of Sections 133, 134, 136, 137, 139, 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, 155.37, 355.2, 355.3, 355b, 356v,
356z.10, 356z.21, 356z.22, 356z.24, 368a, 401, 401.1, 402, 403,
403A, 408, 408.2, 409, 412, 444, and 444.1 and Articles IIA,

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VIII 1/2, XII, XII 1/2, XIII, XIII 1/2, XXV, and XXVI of the
Illinois Insurance Code. For purposes of the Illinois Insurance
Code, except for Sections 444 and 444.1 and Articles XIII and
XIII 1/2, limited health service organizations in the following
categories are deemed to be domestic companies:
(1) a corporation under the laws of this State; or
(2) a corporation organized under the laws of another
state, 30% of 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.
(Source: P.A. 97-486, eff. 1-1-12; 97-592, 1-1-12; 97-805, eff.
1-1-13; 97-813, eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091,
eff. 1-1-15.)
Section 35. The Managed Care Reform and Patient Rights Act
is amended by changing Section 10 and by adding Section 31 as
follows:
(215 ILCS 134/10)
Sec. 10. Definitions.
"Adverse determination" means a determination by a health
care plan under Section 45 or by a utilization review program
under Section 85 that a health care service is not medically
necessary.

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"Clinical peer" means a health care professional who is in
the same profession and the same or similar specialty as the
health care provider who typically manages the medical
condition, procedures, or treatment under review.
"Department" means the Department of Insurance.
"Emergency medical condition" means a medical condition
manifesting itself by acute symptoms of sufficient severity
(including, but not limited to, severe pain) such that a
prudent layperson, who possesses an average knowledge of health
and medicine, could reasonably expect the absence of immediate
medical attention to result in:
(1) placing the health of the individual (or, with
respect to a pregnant woman, the health of the woman or her
unborn child) in serious jeopardy;
(2) serious impairment to bodily functions; or
(3) serious dysfunction of any bodily organ or part.
"Emergency medical screening examination" means a medical
screening examination and evaluation by a physician licensed to
practice medicine in all its branches, or to the extent
permitted by applicable laws, by other appropriately licensed
personnel under the supervision of or in collaboration with a
physician licensed to practice medicine in all its branches to
determine whether the need for emergency services exists.
"Emergency services" means, with respect to an enrollee of
a health care plan, transportation services, including but not
limited to ambulance services, and covered inpatient and

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outpatient hospital services furnished by a provider qualified
to furnish those services that are needed to evaluate or
stabilize an emergency medical condition. "Emergency services"
does not refer to post-stabilization medical services.
"Enrollee" means any person and his or her dependents
enrolled in or covered by a health care plan.
"Health care plan" means a plan, including, but not limited
to, a health maintenance organization, a managed care community
network as defined in the Illinois Public Aid Code, or an
accountable care entity as defined in the Illinois Public Aid
Code that receives capitated payments to cover medical services
from the Department of Healthcare and Family Services, that
establishes, operates, or maintains a network of health care
providers that has entered into an agreement with the plan to
provide health care services to enrollees to whom the plan has
the ultimate obligation to arrange for the provision of or
payment for services through organizational arrangements for
ongoing quality assurance, utilization review programs, or
dispute resolution. Nothing in this definition shall be
construed to mean that an independent practice association or a
physician hospital organization that subcontracts with a
health care plan is, for purposes of that subcontract, a health
care plan.
For purposes of this definition, "health care plan" shall
not include the following:
(1) indemnity health insurance policies including

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those using a contracted provider network;
(2) health care plans that offer only dental or only
vision coverage;
(3) preferred provider administrators, as defined in
Section 370g(g) of the Illinois Insurance Code;
(4) employee or employer self-insured health benefit
plans under the federal Employee Retirement Income
Security Act of 1974;
(5) health care provided pursuant to the Workers'
Compensation Act or the Workers' Occupational Diseases
Act; and
(6) not-for-profit voluntary health services plans
with health maintenance organization authority in
existence as of January 1, 1999 that are affiliated with a
union and that only extend coverage to union members and
their dependents.
"Health care professional" means a physician, a registered
professional nurse, or other individual appropriately licensed
or registered to provide health care services.
"Health care provider" means any physician, hospital
facility, facility licensed under the Nursing Home Care Act,
long-term care facility as defined in Section 1-113 of the
Nursing Home Care Act, or other person that is licensed or
otherwise authorized to deliver health care services. Nothing
in this Act shall be construed to define Independent Practice
Associations or Physician-Hospital Organizations as health

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care providers.
"Health care services" means any services included in the
furnishing to any individual of medical care, or the
hospitalization incident to the furnishing of such care, as
well as the furnishing to any person of any and all other
services for the purpose of preventing, alleviating, curing, or
healing human illness or injury including home health and
pharmaceutical services and products.
"Medical director" means a physician licensed in any state
to practice medicine in all its branches appointed by a health
care plan.
"Medically necessary" means that a treating, consulting,
ordering, or attending physician or health care professional or
provider recommended, ordered, or provided a health care
service, device, drug, or supply appropriate to the evaluation
and treatment of disease, condition, illness, or injury and
consistent with the applicable standard of care, including the
evaluation of experimental or investigational services,
procedures, drugs, or devices.
"Person" means a corporation, association, partnership,
limited liability company, sole proprietorship, or any other
legal entity.
"Physician" means a person licensed under the Medical
Practice Act of 1987.
"Post-stabilization medical services" means health care
services provided to an enrollee that are furnished in a

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licensed hospital by a provider that is qualified to furnish
such services, and determined to be medically necessary and
directly related to the emergency medical condition following
stabilization.
"Stabilization" means, with respect to an emergency
medical condition, to provide such medical treatment of the
condition as may be necessary to assure, within reasonable
medical probability, that no material deterioration of the
condition is likely to result.
"Utilization review" means the evaluation of the medical
necessity, appropriateness, and efficiency of the use of health
care services, procedures, and facilities.
"Utilization review program" means a program established
by a person to perform utilization review.
(Source: P.A. 98-651, eff. 6-16-14; 98-841, eff. 8-1-14; 99-78,
eff. 7-20-15.)
(215 ILCS 134/31 new)
Sec. 31. Medical necessity determinations. On and after the
effective date of this amendatory Act of the 99th General
Assembly, no health care plan shall: (1) provide or refer to a
coverage determination as medically necessary in any
publication, policy, contract or agreement, or explanation of
benefits made by policy or plan or (2) provide or state in any
way that treatment or services recommended by the insured or
enrollees treating, consulting, ordering, or attending

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physician or health care provider is not medically necessary,
to do so shall be considered an unfair and deceptive practice
under the Illinois Insurance Code. Nothing in this Section
shall prohibit a health care benefit determination with respect
to whether treatment or services are covered under the policy
or plan.
Section 40. 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, 136, 139, 140,
143, 143c, 149, 155.22a, 155.37, 354, 355.2, 355.3, 355b, 356g,
356g.5, 356g.5-1, 356r, 356t, 356u, 356v, 356w, 356x, 356y,
356z.1, 356z.2, 356z.4, 356z.5, 356z.6, 356z.8, 356z.9,
356z.10, 356z.11, 356z.12, 356z.13, 356z.14, 356z.15, 356z.18,
356z.19, 356z.21, 356z.22, 356z.24, 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.
Rulemaking authority to implement Public Act 95-1045, 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

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Administrative Rules; any purported rule not so adopted, for
whatever reason, is unauthorized.
(Source: P.A. 97-282, eff. 8-9-11; 97-343, eff. 1-1-12; 97-486,
eff. 1-1-12; 97-592, eff. 1-1-12; 97-805, eff. 1-1-13; 97-813,
eff. 7-13-12; 98-189, eff. 1-1-14; 98-1091, eff. 1-1-15.)
Section 45. The Illinois Public Aid Code is amended by
changing Section 5-16.8 as follows:
(305 ILCS 5/5-16.8)
Sec. 5-16.8. Required health benefits. The medical
assistance program shall (i) 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, and 356z.6 of the
Illinois Insurance Code and (ii) be subject to the provisions
of Sections 356z.19, 356z.24, 364.01, 370c, and 370c.1 of the
Illinois Insurance Code.
On and after July 1, 2012, the Department shall reduce any
rate of reimbursement for services or other payments or alter
any methodologies authorized by this Code to reduce any rate of
reimbursement for services or other payments in accordance with
Section 5-5e.
To ensure full access to the benefits set forth in this
Section, on and after January 1, 2016, the Department shall
ensure that provider and hospital reimbursement for

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post-mastectomy care benefits required under this Section are
no lower than the Medicare reimbursement rate.
(Source: P.A. 99-433, eff. 8-21-15; 99-480, eff. 9-9-15;
revised 10-21-15.)